Provider Demographics
NPI:1225721665
Name:DOMINGUEZ, CHRISTINA MARIE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23887 NORMA DR
Mailing Address - Street 2:
Mailing Address - City:QUAIL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9430
Mailing Address - Country:US
Mailing Address - Phone:951-229-3925
Mailing Address - Fax:
Practice Address - Street 1:23887 NORMA DR
Practice Address - Street 2:
Practice Address - City:QUAIL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92587-9430
Practice Address - Country:US
Practice Address - Phone:951-229-3925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106560106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist